|Year : 2016 | Volume
| Issue : 4 | Page : 213-218
Effects of cannabis use on cognitive function and clinical features of bipolar disorder
Ajay Halder1, Sikha Mukhopadhyay1, Partha Sarathy Biswas1, Abhinanda Biswas2
1 Department of Psychiatry, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
2 Department of General Medicine, ESI Hospital, Belur, Howrah, West Bengal, India
|Date of Web Publication||2-Sep-2016|
Dr. Ajay Halder
Puspak Apartment, GR-FR, FL-A, 14/17A, East Mall Road, Kolkata - 700 080, West Bengal
Source of Support: None, Conflict of Interest: None
Aims: This study aims to compare the cognitive function of patients having dual diagnosis of bipolar affective disorder and cannabis dependence with those having either diagnosis alone and with healthy controls. Settings and Design: Hospital-based study. Subjects and Methods: Study subjects were selected from patients attending psychiatry outpatient department in the presence of two senior consultant psychiatrists. Among the pool of the patients, only those who meet the inclusion and exclusion criteria were selected for the study. Then the selected patients were administered the semi-structured sociodemographic data sheet, Young Mania Rating Scale, Hamilton Depression Rating Scale, General Health Questionnaire-12, Trail Making Test Part A and Part B, verbal fluency tests, Stroop Neuropsychological Screening Test, clock drawing test. Statistical analysis was done by using appropriate statistical methods. Statistical analysis was done with the help of Statistical Package for Social Science-20 (SPSS-20, International Business Machines Corporation (IBM)). Results: The results of our study showed there was significant impairment of cognitive function of the patients of bipolar with cannabis dependence than the patients of bipolar disorder or cannabis dependence alone. It had been also found that with an increase in age of onset of bipolar disorder, there was decrease in no of episode, decrease current duration, and inter-episodic recovery was better. Conclusions: The significant cognitive function impairment exists in bipolar with cannabis dependence and the severity of bipolar outcome correlate with the extent of cannabis use also. In spite of certain limitations such as small sample size, short follow-up time, absence of Indian version of neuropsychological tests, and referral bias inherent in hospital-based studies; present study provides valuable empirical insight into complex relationship between cannabis dependence, bipolar disorder, and cognitive dysfunction.
Keywords: Bipolar disorder, cannabis, cognition
|How to cite this article:|
Halder A, Mukhopadhyay S, Biswas PS, Biswas A. Effects of cannabis use on cognitive function and clinical features of bipolar disorder. Int J Educ Psychol Res 2016;2:213-8
|How to cite this URL:|
Halder A, Mukhopadhyay S, Biswas PS, Biswas A. Effects of cannabis use on cognitive function and clinical features of bipolar disorder. Int J Educ Psychol Res [serial online] 2016 [cited 2019 Nov 17];2:213-8. Available from: http://www.ijeprjournal.org/text.asp?2016/2/4/213/189677
| Introduction|| |
Bipolar disorder or bipolar affective disorder, historically known as manic-depressive disorder, is a psychiatric diagnosis that describes a category of mood disorders defined by the presence of one or more episodes of abnormally elevated energy levels, cognition and mood with or without one or more depressive episodes/mixed episodes. When broadly defined 4% of people experience bipolar at some point in their life. It is equally prevalent in men and women and is found across all cultures and ethnic groups.
On the other hand, cognition refers to mental processes. These processes include attention, remembering, producing, and understanding language, solving problems, and making decisions. It usually refers to an information processing view of an individual's psychological functions.
Cannabis dependence is a condition defined in Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV) applying the general concept of substance dependence to cannabis. About 147 million people, 2.5% of the world population, consume cannabis (annual prevalence) compared with 0.2% consuming cocaine and 0.2% consuming opiates (WHO 2011).
Subjects with bipolar disorder very often struggle with substance abuse and dependence., Typically, cannabis is the most commonly abused drug in individuals with bipolar disorder., Recent studies have demonstrated changes in cognition and brain function associated with long-term or frequent use of cannabis. Specific impairments of attention, memory, and executive function have been found in cannabis users in the unintoxicated state in controlled studies using brain event-related potential techniques  and neuropsychological assessments , including complex tasks. Cognitive dysfunction seems to predict a poorer functional outcome among bipolar disorder patients, and it is possible that cognitive deficits of greater severity in dually diagnosed patients contribute to this unfavorable outcome.
Acutely bipolar with cannabis dependence patients have shown dysfunctions in several cognitive areas, such as attention, executive function, learning and memory and psychomotor speed.,, However, it remains unclear whether neuropsychological deficits are stable and exist independently of clinical state.
It is reported that there is a significant reduction of hippocampus and amygdale volumes in long-term heavy cannabis users (mean age 40, mean duration of use 20 years). Early onset cannabis users (before age 17) were found to have smaller whole brain volumes, lower percent cortical gray matter, higher percent white matter, and increased resting cerebral blood flow compared to later onset users. Recent evidence of diminished neuronal and axonal integrity in the dorsolateral prefrontal cortex indicated by magnetic resonance spectroscopic markers of metabolism (the ratio N-acetylaspartate/total creatine) was reported.
| Subjects and Methods|| |
- Place of study: The study was conducted in the Outpatient Department of Psychiatry, Institute of Post Graduate Medical Education and Research, Kolkata
- Duration of study: 18 months (January 2012 to June 2013)
- Sample size: The samples comprise four groups of 30 subjects each, aged 18–45 years.
- Bipolar affective disorders with cannabis dependence (BC)
- Bipolar affective disorders without cannabis dependence (B)
- cannabis dependence (C)
- Normal healthy control group (H).
- Tools: Semi-structured sociodemographic data sheet, Young Mania Rating Scale, Hamilton Depression Rating Scale, DSM-IV-text revision (DSM-IV-TR), General Health Questionnaire-12 for screening of controls
- Cognitive function assessment: Trail Making Test Part A and Part B, verbal fluency tests, Stroop Neuropsychological Screening Test (SNST), clock drawing test.
Study subjects were selected by purposive sampling from patients, diagnosed by two senior consultant psychiatrists as having bipolar affective disorder with/without cannabis dependence and cannabis dependence as per DSM-IV-TR criteria.
After being explained about the risk and benefit associated with the study in details in a language they understand properly, patients provided informed consent mentioning their willingness for voluntary participation in the study.
Then the selected patients were administered the semi-structured proforma for assessment of demographic variables named age, sex, type of residence, occupation, and years of formal education, the age at onset, duration of illness in years, number of affective episodes, etc.
The patients were administered the tests for measurement of cognitive functions, i.e. verbal fluency, clock drawing test, Trail Making Test A and B and SNST.
Score of each test was noted according to the instruction or manual of the respective tests.
| Results|| |
Age of onset of bipolar disorder had got statistically significant negative correlation with no of episode (P < 0.01), current duration (P < 0.01), and had got significant positive correlation with inter-episodic recovery (P < 0.01), that means with increase in age of onset of bipolar disorder, there was decrease in no of episode, decrease current duration, and inter-episodic recovery was better.
Mean numbers of duration of current affective episode by the patient groups BC and B were BC (6.97 ± 2.760 [standard deviation (SD)]), B (5.37 ± 2.671 [SD]). The difference was statistically significant (t = 2.281; P = 0.026). It means duration of current mood episode is much longer to bipolar with cannabis dependence patients than the cannabis dependence alone.
| Discussion|| |
This study was a hospital based cross-sectional study, undertaken with the aim to find out the effect of cannabis use on cognitive function and clinical features of bipolar disorder. The study also intended to search for the affection of different domains of cognitive function, if any. Moreover, it also tried to track the course of changes in clinical features of bipolar disorder in patients who had a history of bipolar disorder.
In [Table 1], all four groups (BC, B, C, H) were comparable and matched as far their marital status (P = 0.578), religion (P = 0.806), living arrangements (P = 0.304), residence (P = 0.883), education (P = 0.224), socioeconomic status (P = 0.630), family history (P = 0.760), and legal problem (P = 0.278). All these signify that there was homogenous selection of patients in this study.
Analyzing in [Table 2], we can find that there were significant differences in all aspects. Hence, bipolar patients having cannabis dependence were impaired most in these domains of cognitive function. These findings also corroborate with previous studies.,,,,, The difference of clock drawing score between patients BC (1.03 ± 0.764 [SD]), B (1.60 ± 0.894 [SD]), C (1.66 ± 0.884 [SD]), H (2.16 ± 0.746 [SD]) were also statistically significant (F = 9.479; P < 0.001). Here also Group BC performed worse than Group B, Group C, and Group H.
Completion of trail making Part B test also needed more time for a patient of Group BC and the difference was found statistically significant (F = 7.365; P < 0.001).
Trail Making Tests looks into attention, psychomotor speed, flexibility of thinking, working memory, implementation of volitional activities, adjusting and stopping volitional activities, inhibitory control, and set shifting strategy.,,,,, Hence, bipolar patients having cannabis dependence were impaired most in these domains of cognitive function than bipolar without cannabis dependence and cannabis dependence alone.,,,,
Stroop color test score were BC (95.86 ± 8.66 [SD]), B (100.90 ± 7.89 [SD]), C (101.03 ± 6.61 [SD]), and H (106.83 ± 3.54 [SD]) and this was also statistically significant (F12.450, P < 0.001).
Stroop test measures certain aspects of executive function such as reaction time, cognitive flexibility, complex, selective and sustained attention, automatic information processing, inhibitory control, i.e., response inhibition, focused effort, reaction time, and cognitive flexibility.,,,, Hence, bipolar patients having cannabis dependence were impaired most in these domains of cognitive function than bipolar without cannabis dependence and cannabis dependence alone.,
In [Table 3]a, type of current episode in Group BC were Depression 9 (30%), hypomania 4 (13.3%), mania 12 (40%), mixed episode 5 (16.7%). On the other side, current episode Depression 13 (43.3%), hypomania 3 (10%), mania 10 (33.3%), mixed episode 4 (13.3%) in the group B (t=1.261, P=0.762).
In [Table 3]b, the correlation between different features of bipolar disorder among the patients belonging to Group BC and Group B had been described.
Age of onset of bipolar disorder had got statistically significant negative correlation with no of episode (P < 0.01), current duration (P < 0.01), and had got significant positive correlation with inter-episodic recovery (P < 0.01). That means with an increase in Age of onset of bipolar disorder; there was decrease in no of episode, current duration, and inter-episodic recovery was better.,,,
In [Table 3]c, mean numbers of duration of current affective episode by the patient groups BC and B were BC (6.97 ± 2.760 [SD]), B (5.37 ± 2.671 [SD]). The difference was statistically significant (t = 2.281; P = 0.026).,
The results of our study showed there was significant impairment of cognitive function of the patients of bipolar with cannabis dependence than the patients of bipolar disorder or cannabis dependence alone which were significant and matched with most of the studies. It had been also found that with increase in age of onset of bipolar disorder, there was decrease in no of episode, decrease current duration and inter-episodic recovery was better.
From this study, we ultimately conclude that significant cognitive function impairment exists in bipolar with cannabis dependence and the severity of bipolar outcome correlate with the extent of cannabis use also. This finding has got an important neurobiological implication in a future study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ketter TA. Diagnostic features, prevalence, and impact of bipolar disorder. J Clin Psychiatry 2010;71:e14.
Goodwin FK, Jamison KR. “Epidemiology”. Manic-Depressive Illness. Oxford University Press; 1990. Ch. 7: 233-244.
Angst J. comorbidity of mood disorders: A longitudinal prospective study. Br J Psychiatry Suppl 1996;30:31-7.
Strakowski SM, DelBello MP, Fleck DE, Arndt S. The impact of substance abuse on the course of bipolar disorder. Biol Psychiatry 2000;48:477-85.
Strakowski SM, McElroy SL, Keck PE Jr., West SA. The effects of antecedent substance abuse on the development of first-episode psychotic mania. J Psychiatr Res 1996;30:59-68.
Compton WM, Grant BF, Colliver JD, Glantz MD, Stinson FS. Prevalence of marijuana use disorders in the United States: 1991-1992 and 2001-2002. JAMA 2004;291:2114-21.
Solowij N. Cannabis and Cognitive Functioning. Cambridge: Cambridge University Press; 1998.
Fletcher JM, Page JB, Francis DJ, Copeland K, Naus MJ, Davis CM, et al.
Cognitive correlates of long-term cannabis use in Costa Rican men. Arch Gen Psychiatry 1996;53:1051-7.
Solowij N, Grenyer BF, Peters R, Chesher G. Long term cannabis use impairs memory processes and frontal lobe function. In: 1997 Symposium on the Cannabinoids. Burlington, Vt: International Cannabinoid Research Society; 1997. p. 84.
Cahill CM, Malhi GS, Ivanovski B, Lagopoulos J, Cohen M. Cognitive compromise in bipolar disorder with chronic cannabis use: Cause or consequence? Expert Rev Neurother 2006;6:591-8.
Martínez-Arán A, Vieta E, Colom F, Reinares M, Benabarre A, Gastó C, et al.
Cognitive dysfunctions in bipolar disorder: Evidence of neuropsychological disturbances. Psychother Psychosom 2000;69:2-18.
Bearden CE, Hoffman KM, Cannon TD. The neuropsychology and neuroanatomy of bipolar affective disorder: A critical review. Bipolar Disord 2001;3:106-50.
Quraishi S, Frangou S. Neuropsychology of bipolar disorder: A review. J Affect Disord 2002;72:209-26.
Yücel M, Solowij N, Respondek C, Whittle S, Fornito A, Pantelis C, et al
. Regional brain abnormalities associated with long-term heavy cannabis use. Arch Gen Psychiatry 2008;65:694-701.
Wilson W, Mathew R, Turkington T, Hawk T, Coleman RE, Provenzale J. Brain morphological changes and early marijuana use: A magnetic resonance and positron emission tomography study. J Addict Dis 2000;19:1-22.
Hermann D, Sartorius A, Welzel H, Walter S, Skopp G, Ende G, et al.
Dorsolateral prefrontal cortex N-acetylaspartate/total creatine (NAA/tCr) loss in male recreational cannabis users. Biol Psychiatry 2007;61:1281-9.
Bannerjee S, Mukhopadhyay A, Shukla V. Cognitive deterioration of male drug addicts. J Indian Acad Appl Psychol 1997;23:13-8.
Gruber SA, Yurgelun-Todd DA. Neuropsychological deficits in marijuana smokers. Arch Clin Neuropsychol 1996;11:397.
Ferrier IN, Stanton BR, Kelly TP, Scott J. Neuropsychological function in euthymic patients with bipolar disorder. Br J Psychiatry 1999;175:246-51.
Clark L, Iversen SD, Goodwin GM. Sustained attention deficit in bipolar disorder. Br J Psychiatry 2002;180:313-9.
Thompson JM, Gallagher P, Hughes JH, Watson S, Gray JM, Ferrier IN, et al.
Neurocognitive impairment in euthymic patients with bipolar affective disorder. Br J Psychiatry 2005;186:32-40.
Albus M, Hubmann W, Wahlheim C, Sobizack N, Franz U, Mohr F. Contrasts in neuropsychological test profile between patients with first-episode schizophrenia and first-episode affective disorders. Acta Psychiatr Scand 1996;94:87-93.
Preiss M, Kucerova H, Lukavsky J, Stepankova H, Sos P, Kawaciukova R. Cognitive deficits in the euthymic phase of unipolar depression. Psychiatry Res 2009;169:235-9.
Marvel CL, Paradiso S. Cognitive and neurological impairment in mood disorders. Psychiatr Clin North Am 2004;27:19-36, vii-viii.
Hill SK, Keshavan MS, Thase ME, Sweeney JA. Neuropsychological dysfunction in antipsychotic-naive first-episode unipolar psychotic depression. Am J Psychiatry 2004;161:996-1003.
Bhatia T, Shriharsh V, Adlakha S, Bisht V, Garg K, Deshpande SN. The Trail Making Test in India. Indian J Psychiatry 2007;49:113-6.
Cummings JL, Miller BL, editors. Conceptual and clinical aspects of the frontal lobes. In: The Human Frontal Lobes. 2nd
ed. New York: The Guilford Press; 2007. p. 16-8.
Mondal S, Sharma VK, Das S, Goswami U, Gandhi A. Neuro-cognitive functions in patients of major depression. Indian J Physiol Pharmacol 2007;51:69-75.
Pope HG Jr., Gruber AJ, Yurgelun-Todd D. The residual neuropsychological effects of cannabis: The current status of research. Drug Alcohol Depend 1995;38:25-34.
Pope HG Jr., Yurgelun-Todd D. The residual cognitive effects of heavy marijuana use in college students. JAMA 1996;275:521-7.
Fletcher PC, Honey GD. Schizophrenia, ketamine and cannabis: Evidence of overlapping memory deficits. Trends Cogn Sci 2006;10:167-74.
Struve FA, Straumanis JJ, Patrick G, Leavitt J, Manno JE, Manno BR. Topographic quantitative EEG sequelae of chronic marihuana use: A replication using medically and psychiatrically screened normal subjects. Drug Alcohol Depend 1999;56:167-79.
Cavanagh JT, Van Beck M, Muir W, Blackwood DH. Case-control study of neurocognitive function in euthymic patients with bipolar disorder: An association with mania. Br J Psychiatry 2002;180:320-6.
Stordal KI, Lundervold AJ, Egeland J, Mykletun A, Asbjørnsen A, Landrø NI, et al.
Impairment across executive functions in recurrent major depression. Nord J Psychiatry 2004;58:41-7.
Stordal KI, Lundervold AJ, Mykletun A, Asbjørnsen A, Biringer E, Egeland J, et al.
Frequency and characteristics of recurrent major depressed patients with unimpaired executive functions. World J Biol Psychiatry 2005;6:36-44.
Gohier B, Ferracci L, Surguladze SA, Lawrence E, El Hage W, Kefi MZ, et al.
Cognitive inhibition and working memory in unipolar depression. J Affect Disord 2009;116:100-5.
Markela-Lerenc J, Kaiser S, Fiedler P, Weisbrod M, Mundt C. Stroop performance in depressive patients: A preliminary report. J Affect Disord 2006;94:261-7.
Ravnkilde B, Videbech P, Clemmensen K, Egander A, Rasmussen NA, Rosenberg R. Cognitive deficits in major depression. Scand J Psychol 2002;43:239-51.
Patrick G, Struve FA. Reduction of auditory P50 gating response in marihuana users: Further supporting data. Clin Electroencephalogr 2000;31:88-93.
Pope HG Jr., Gruber AJ, Yurgelun-Todd D. Residual neuropsychologic effects of cannabis. Curr Psychiatry Rep 2001;3:507-12.
Ranganathan M, D'Souza DC. The acute effects of cannabinoids on memory in humans: A review. Psychopharmacology (Berl) 2006;188:425-44.
Egerton A, Allison C, Brett RR, Pratt JA. Cannabinoids and prefrontal cortical function: Insights from preclinical studies. Neurosci Biobehav Rev 2006;30:680-95.
Calabrese JR, Shelton MD, Bowden CL, Rapport DJ, Suppes T, Shirley ER, et al.
Bipolar rapid cycling: Focus on depression as its hallmark. J Clin Psychiatry 2001;62 Suppl 14:34-41.
Strakowski SM, Sax KW, McElroy SL, Keck PE Jr., Hawkins JM, West SA. Course of psychiatric and substance abuse syndromes co-occurring with bipolar disorder after a first psychiatric hospitalization. J Clin Psychiatry 1998;59:465-71.
Tohen M, Waternaux CM, Tsuang MT. Outcome in mania. A 4-year prospective follow-up of 75 patients utilizing survival analysis. Arch Gen Psychiatry 1990;47:1106-11.
Goldberg JF, Garno JL, Leon AC, Kocsis JH, Portera L. A history of substance abuse complicates remission from acute mania in bipolar disorder. J Clin Psychiatry 1999;60:733-40.
[Table 1], [Table 2], [Table 3]